Healthcare Provider Details

I. General information

NPI: 1508580903
Provider Name (Legal Business Name): LENNARD THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 N 19TH AVE APT 2071
PHOENIX AZ
85021-5276
US

IV. Provider business mailing address

8330 N 19TH AVE APT 2071
PHOENIX AZ
85021-5276
US

V. Phone/Fax

Practice location:
  • Phone: 347-854-2687
  • Fax:
Mailing address:
  • Phone: 347-854-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: